Provider Demographics
NPI:1417599945
Name:MIRACLE COMPREHENSIVE SERIVCES
Entity Type:Organization
Organization Name:MIRACLE COMPREHENSIVE SERIVCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EME
Authorized Official - Middle Name:
Authorized Official - Last Name:UDOETUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-769-1737
Mailing Address - Street 1:4440 LINCOLN HWY STE 205
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-3803
Mailing Address - Country:US
Mailing Address - Phone:708-769-1737
Mailing Address - Fax:
Practice Address - Street 1:4440 LINCOLN HWY STE 205
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-3803
Practice Address - Country:US
Practice Address - Phone:708-769-1737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities